Client terms, conditions and informed consent to treatment
Thank you for choosing YourPath Care, PLLC (“YourPath Care” or “we”), an affiliate of YourPath, Inc. Our licensed physicians, nurse practitioners, and other health care professionals provide individualized substance use disorder and/or mental health treatment in a supportive environment. For convenience, these health care professionals are collectively referred to in this document as “your Provider.”
This document contains important information about our professional services and business policies. Please carefully read this document and talk with your Provider if you have any questions or concerns.
Scheduling Appointments, Cancellation Policy, and Late Arrival Policy
Scheduling Appointments. Please call us at (612) 895-1512 during the normal business hours to make an appointment.
Cancelling or Rescheduling Appointments. You must provide at least 24 hours’ notice of the need to cancel or reschedule an appointment by calling us at (612) 895-1512. If you do not provide this notice, we may charge you for the missed appointment. Insurance companies and other third-party payors may not reimburse you for these charges.
Late Arrival Policy. Please be on-time for all appointments. We will charge you the full fee for your appointments, even if you arrive late. We reserve the right to cancel your appointment, without refund, if you are more than 10 minutes late to an appointment.
Available Services; Affiliated Providers
YourPath Inc. and its affiliates offer individualized and person-centered substance use disorder and/or mental health treatment, including but not limited to mental health and substance use disorder assessments, counseling, care coordination services, and medications for psychiatric and substance use disorders. Some recommended services may be offered by other YourPath, Inc. providers that are separate from, but closely affiliated with, us. We will tell you about our relationship to these affiliated providers before you receive services from them, and you always have the right to obtain services from an unaffiliated provider. If you choose to receive such services from an unaffiliated provider, we will provide you with the names and contact information of other service providers.
Confidentiality
We will keep information about you confidential unless you authorize the disclosure of your information or if a disclosure is permitted or required by applicable law. Applicable law includes, but is not limited to, the Health Insurance Portability and Accountability Act (HIPAA), 42 CFR Part 2, and the Minnesota Health Records Act. More information about how we will use and disclose information about you is found in our Notice of Privacy Practices.
No Guaranteed Outcome; Assumption of Treatment-Related Risks
We do not guarantee the results of our services which, like all health care services, carry both potential risks and benefits. We will talk with you about these potential risks and benefits, and treatment alternatives, before you sign this document, and answer any questions that you may have.
Contacting Your Provider
Emergencies. We do not provide 24-hour care. In the event of an emergency, including a mental health crisis, immediately call 911 and/or go to the nearest emergency room.
Non-Emergencies. If you need to talk to your Provider before your next appointment, call (612) 895-1512 and leave a message for your Provider. Include your name, telephone number, and availability in your message. Your Provider will return your call as soon as possible, typically within one business day. If your Provider is unavailable for an extended period of time (for example, due to illness), another member of our care team will return your call.
Email and Text Messages. Information sent to or by us via email, text, or other electronic means is not secure. You agree to receive email and text messages that confirm the date, time, and location of your appointments, and understand that you can opt-out of receiving these messages at any time by notifying your Provider. These emails will not include additional information about your treatment. You are responsible for, and assume all risks relating to, the security of any information that you send to us via email, text, our website, or other electronic means.
Social Media. Your Provider does not accept friend or connection requests from current or former clients, and will not communicate with you on any social media platform (for example, Facebook, Instagram, TikTok, etc.). Do not directly or indirectly try to gain access to the personal social media accounts of any of our staff, including your Provider. We reserve the right to terminate your treatment with us if you try to gain this access.
Telehealth Services
You and your Provider may agree that certain services can be effectively provided to you via telehealth. If you choose to receive services via telehealth, you must comply with the following requirements:
Identity and Location Verification. You must verify your identity and your geographical location at the start of each telehealth appointment.
Return to In-Person Services. Depending on your treatment needs, your Provider may recommend that you return to in-person services. If you are unwilling to return to in-person services, your Provider may terminate your treatment services in accordance with applicable law, and will provide you with the names and contact information of other potential providers.
No Recording or Participation by Non-Approved Third Parties. Neither you nor your Provider will (1) record your telehealth appointment without the prior written permission of your Provider (when you are recording) or you (when your Provider is recording); or (2) allow any third parties to watch, listen, or record your telehealth appointment without the knowledge and consent of both you and your Provider. You understand and agree that we may make recordings for security or training purposes, and that such recordings do not violate this paragraph.
Securing Your Equipment and Environment. You are responsible for securing and protecting any equipment that you use during a telehealth appointment, and ensuring that your telehealth appointment cannot be overheard or recorded. We strongly recommend protecting your computer and files with complex passwords, fully exiting all programs at the conclusion of your telehealth appointment, and attending your telehealth appointment in a private location.
Technology Failures. If you are disconnected from your Provider during a telehealth appointment, please wait five minutes and try to reconnect. If your reconnection attempt is unsuccessful, call us at (612) 895-1512 for assistance.
Privacy and Security Risks. There are privacy and security risks to receiving services via telehealth. These risks include, but are not limited to, (1) technical failures resulting in interrupted or distorted communications and data transmission; and (2) interception of your protected health information by hackers and other unauthorized persons. In an effort to minimize these risks, we have implemented commercially reasonable safeguards to protect the confidentiality of your information. However, the use of these safeguards cannot and does not guarantee the privacy and security of information shared during your telehealth appointment. By choosing to receive telehealth services, you acknowledge the privacy and security risks inherent in the provision of services via telehealth, and agree to assume all such risks
Payment for Services
You agree to pay for all the services that we provide to you. A good faith estimate of the cost of our services is available to you upon request. We may change our fees at any time, and will provide you with at least 30 days’ notice of any fee increase. If you are unwilling or unable to pay the increased fee, we may terminate your services and provide you with the name and contact information of other potential providers.
You are responsible for providing us with the information needed to bill your health insurer, government program benefits or other third-party payor for the services we provide to you. All insurance co-payments are due at the time of service. By providing us with your insurance and benefits information, you are consenting to our disclosure of your protected health information, including information relating to your substance use disorder and/or mental health disorder, to your health insurer, government program benefits or other third-party payor to the extent needed to determine coverage, and obtain payment, for our services. You may revoke this consent at any time by providing us with written notice.
To the extent permitted by applicable law and our contractual obligations, you agree to pay any fees that are not paid in full by your health insurer, government program benefits or other third-party payors, upon receipt of a statement. You further agree to pay or reimburse us for all costs incurred in collecting such amounts. If you have questions about your insurance or benefits coverage, please contact your insurance or benefits provider.
Payment for Records and Testimony
To the extent permitted by law, you are financially responsible for paying for costs incurred by us to respond to a request for information relating to (1) any disagreement between you and another person; or (2) the alleged commission of a crime by you. For example, we may incur costs when responding to a subpoena for records, or when traveling to and participating in a deposition or court hearing. We will calculate these costs based on our standard rate at the time the costs are incurred. You must pay these costs, in full, within 10 days of our request for payment, which we may make before or after we incur the costs. All such payments are non-refundable.
Dispute Resolution; Legal Fees
Dispute Resolution; Legal Fees. The parties shall make a good faith effort to informally resolve any dispute, claim or controversy arising out of or relating to this Agreement by arbitration, which shall be conducted under the then current arbitration procedures of the American Arbitration Association. The parties agree that their respective good faith participation in arbitration is a condition precedent to pursuing any other available legal or equitable remedy, including litigation. If any legal action or any arbitration or other proceeding is brought for the enforcement of this Agreement, or because of an alleged dispute, breach, default or misrepresentation in connection with any of the provisions of this Agreement, the successful or prevailing party or parties shall be entitled to recover reasonable attorneys’ fees and other costs incurred in that action or proceeding, in addition to any other relief to which it or they may be entitled.
Governing Law and Venue for Legal Disputes. This Agreement shall be construed in accordance with, and governed by, the laws of the State of Minnesota. The exclusive venue for any court proceeding based on or arising out of this Agreement shall be Hennepin County or Ramsey County, Minnesota.
Severability. If a court of competent jurisdiction determines that any provision contained in this document is unenforceable, such provision shall be deemed struck, and all other provisions shall remain in full force and effect.
Consent and Authorization to Release Your Health Information to Affiliated YourPath Programs for Care Coordination.
YourPath Care provides services in connection with other programs operated by or in conjunction with YourPath, Inc., including, without limitation, those operated by YourPath, LLC and PJG Medical, LLC (collectively, the “YourPath Programs”). In order to facilitate your care and appropriate referrals, YourPath Programs share information and access to your health information. This consent to release information does impact your freedom of choice in selecting your providers and your ability to choose to work with a provider or program other than the YourPath Programs.
As a condition to receiving treatment services from YourPath Care, you, the client named below, consent to the use and disclosure of your health information among YourPath Programs for treatment and health care operations purposes. The records released and used by YourPath Programs pursuant to this consent will be re-used and re-disclosed only in accordance with applicable state and federal privacy laws, including 42 C.F.R. Part 2 (Confidentiality of Substance Use Disorder Patient Records). I understand that I will be denied services if I refuse to consent to these disclosures.
This consent will not expire until you revoke your consent in writing. This consent to the release and use of your health information among YourPath Programs will not expire until you notify YourPath Care’s Privacy Officer, in writing, of your revocation. You may revoke your consent at any time. Any such revocation will not apply to any release made in reliance on this consent.
Consent and Authorization to Release Your Health Information for Treatment, Payment, and Health Care Operations
You consent to the use and disclosure of your health information for treatment, payment, and health care operations purposes. YourPath Care may release your health information and records (which include information about your substance use disorder and/or mental health treatment) for the following purposes:
Treatment. YourPath Care may disclose your health information to other health care providers involved in your care or treatment.
Payment. YourPath Care may disclose your health information for various payment-related purposes. For example, YourPath Care may release your health records to your health insurance provider to receive payment for services provided to you by YourPath Care.
Health Care Operations. YourPath Care may disclose your health information to its business associates to support its health care operations. “Health care operations” include, but are not limited to, billing activities, claims management, collections activities, clinical professional support services, business planning and development, general administrative activities, customer services, care coordination, and other activities, as permitted by law.
The records released by YourPath Care pursuant to this consent may be re-used and re-disclosed by the recipient of these records in accordance with applicable state and federal privacy laws. However, 42 C.F.R. Part 2 (Confidentiality of Substance Use Disorder Patient Records) may no longer govern any such re-use and re-disclosure.
YourPath Care does not condition treatment upon this consent to the release of your health records for treatment, payment, or health care operations purposes.
This consent will not expire until you revoke your consent in writing. This consent to the release of your health information for treatment, payment, and health care operations will not expire until you notify YourPath Care’s Privacy Officer, in writing, of your revocation. You may revoke your consent at any time. Any such revocation will not apply to any release made in reliance on this consent.
Acknowledgements and Signature
With your signature you, the client, are acknowledging the following:
You have read, fully understand, and agree to abide by the policies and other information contained in this document. You have had the opportunity to ask any questions that you may have about this document, and all your questions have been answered to your satisfaction.
You understand that you have the right to choose your treatment provider, and can terminate your relationship with us at any time. You further understand that we may recommend treatment services that are available from providers who are affiliated with us, including other YourPath Programs. We will always disclose any such affiliation, and will also provide you with the names and contact information of unaffiliated providers. If you choose to receive services from an affiliated provider, the terms and conditions contained in this document will govern those services unless you sign a separate service agreement with the affiliated provider.
You understand the potential risks, benefits, and alternatives to the substance use disorder and/or mental health treatment and related services provided by us, and consent to the provision of these services. You understand that you can revoke this consent at any time.
You have received a copy of our Notice of Privacy Practices, which we may update from time to time. You know that you can obtain a copy of our current Notice of Privacy Practices from your Provider at any time.
You understand and agree that the results of our services are not guaranteed.